Hand and Wrist BOA Instructional Course Manchester 2019 Prof David - - PowerPoint PPT Presentation

Prof David Warwick

MD FRCS FRCS(Orth) European Diploma of Hand Surgery www.handsurgery.co.uk

Hand and Wrist

BOA Instructional Course Manchester 2019

Dupuytren’s Disease Flexor Tendon Repair Wrist Arthritis Distal Radius Fractures Scapholunate reconstruction

Dupuytren’s Disease Flexor Tendon Repair Wrist Arthritis Distal Radius Fractures Scapholunate reconstruction

Heterogeneity of disease

Stumps Twigs Logs

2018

Different bikes for different terrains

Heterogeneity of disease

Some cords are more suitable for surgery

• diathesis
• dense cords
• skin involvement

Some are more suitable for PNF or Xiapex

• thin MCP cord

We should be thinking of

• ffering more needles

Much quicker Much cheaper Much safer Much quicker return to work

Much more recurrence

Invasive surgical procedures

Developments in surgical technique

Minimally Invasive Procedures

• EVAR
• Laparoscopy/Keyhole
• Lithotripsy

Mainly used after 2000

• Open-heart surgery
• Hysterectomy
• Angioplasty
• Cholecystectomy
• Appendicectomy

All common until 1990s

8

Percutaneous needle fasciotomy recurrence and complications

Study Badois (1993) Foucher (2001) Van Rijssen (2006) Patients 123 hands 100 rays 55 rays

Recurrence 50% (5 yrs) 58% (3.2yrs) 65% (33 months)

Complications

– Nerve injury (0.05% - 2%) – Skin fissure (16 - 46%) – Flexor tendon rupture (0.05%) – Arterial injury – Infection (2%)

Xiapex recurrence

19.6 14.2 33.7 35.2 27.1 56.4

42.4 34.8 62.2

46.7 39.5 65.7 10 20 30 40 50 60 70 80 90 100 Overall (n=623) MP Joints (n=451) PIP Joints (n=172) 2 years 3 years 4 years 5 years

Peimer C, Blazar P, Coleman S, Kaplan T, Smith T, Lindau T. Dupuytren Contracture Recurrence Following Treatment With Collagenase Clostridium Histolyticum (CORDLESS [Collagenase Option for Reduction of Dupuytren Long-Term Evaluation of Safety Study]): 5-Year Data. J Hand Surg (Am) 2015;40:1597-1605

Return to work

PNF



2-7 days

CCH



4-10 days

Fasciectomy



4-8 weeks

Skin graft



6-8 weeks

• Tonkin MA, Burke FD, Varian JPW

(1984) Dupuytren's Contracture: A Comparative Study of Fasciectomy and Dermofasciectomy in One Hundred

• Patients. Journal of Hand Surgery 9: 156
• D. Warwick, et al Collagenase

Clostridium histolyticum in patients with Dupuytren’s contracture: results from POINT X, an open-label study of clinical and patient-reported outcomes J Hand Surg 2015; ;40E: 124-32.

• van Rijssen AL et a J Hand Surg

2006;31A:717–725A Comparison of the Direct Outcomes of Percutaneous Needle Fasciotomy and Limited Fasciectomy for Dupuytren’s Disease: A 6-Week Follow-Up Study

UK data

CCH (Xiapex) “a surgical drug” Theoretically dissolves a segment of cord

• Therefore more effective
• Therefore less recurrence

But is this concept true?

PNF CCH

• PIP only
• RCT 3 year follow
• N=96
• Recurrence
• 43% PNF
• 34% CCH
• Function
• Unchanged
• URAM
• DASH
• N=140
• RCT
• No difference at 1 year
• Recurrence
• Hand function
• N=50
• Initial Correction
• PNF 100%
• CCH 89%
• Recurrence
• PNF 68%
• CCH 83%

PNF works as well as Xiapex PNF is preferable to CCH Quicker (no second manipulation) Safer (no chemical side effects) Cheaper (drug costs 1000 Euros)

Dupuytren’s Disease Flexor Tendon Repair Wrist Arthritis Distal Radius Fractures Scapholunate reconstruction

2018

• Key points
• 4 or 6 strand suture
• Sparse peripheral sutures
• Allow repair to be bulky not gappy
• Aggressive pulley release
• Less wrist restriction in splint
• Early active motion

6 or 4 strand 3-0 or 4-0 Not fibre wire

Functionally relevant bowstringing does not occur if A4 or A2 released Better bowstringing than triggering

The Manchester short splint: A change to splinting practice in the rehabilitation of zone II flexor tendon repairs Peck, Rowe, Duff, Ng, Hand Therapy 2014 19 47-53

• Allows wrist flexion and extension
• Tenodesis
• Early active movement

Dupuytren’s Disease Flexor tendon repair Wrist Arthritis Distal Radius Fractures Scapholunate

Wrist Arthritis

• Wrist replacement is “work in progress”
• Don’t forget neurectomy
• Use preserved cartilage

Wrist Arthritis

• Wrist replacement is “work in progress”
• Don’t forget neurectomy
• Use preserved cartilage

59% complication 39% revision Follow Up 35 +/- 28 months

Yeoh D, Tourret L (2015) Total wrist arthroplasty: A systematic review of the evidence from the last five years. J Hand Surg Eur; 40:458-468

8 articles 405 implants, 7 types

FU 2.3 to 7 years

Motec best DASH Maestro best ROM Universal 2 highest survival Biax 69% complication Remotion lowest complication

The evidence does not support the widespread use of arthroplasty over arthrodesis

❓What journal would publish a THR or TKR paper with such short term results

Unless they are bad results

❓Which surgeon would use implants with such a complication and revision rate And

• No NJR
• No Beyond Compliance

Motec

(Gibbon)

• Uncemented ball and socket
• 110 wrists
• 63 cases > 5 years follow up
• 82% projected survivorship at 10

years

• ROM 125 degrees
• total flexion extension radial tilt ulnar

tilt

• PRWE 25

 Complications

 33% total  9% Revision for loosening  4% fusion for infection/malposition

Wrist Arthritis

• Wrist replacement is “work in progress”
• Don’t forget neurectomy
• Use preserved cartilage

Wrist Denervation

• Hilton1862
• The nerve crossing a joint innervates that joint
• Wilhelm 1959
• Wrist joint denervation
• 5 incisions
• Berger 1998
• Single incision AIN and PIN

• No evidence that proprioception is damaged
• No need for pre-op injections
• Results
• Satisfaction 70-90%
• Good/excellent 70-90%
• Survival 68-85% @ 2.6 years

JHS (2018) 43:272-77

Wrist Arthritis

• Wrist replacement is “work in progress”
• Don’t forget neurectomy
• Preserve cartilage

Review article

Logan J, Warwick D (2015) The treatment of wrist arthritis. Bone Joint J 97-B : 1303-1308

Your own cartilage and subchondral bone is better than metal and plastic

Is there preserved cartilage?

If there is preserved cartilage use it

PRC or 4CF

• Equal clinical outcomes
• 60% ROM
• 80% grip strength
• 80% survivorship 10 years
• PRC
• easier
• safer
• cheaper

Saltzman BM et al. (2015) Clinical outcomes of proximal row carpectomy versus four-corner arthrodesis for post-traumatic wrist arthropathy: A systematic review. J Hand Surg Eur Vol 2015;40:450-457.

SNAC and SLAC is the capitate-lunate involved?

• No
• PRC
• 4CF
• Yes
• 4CF

Do not do

 Replacement  Total fusion

Dupuytren’s Disease Flexor Tendon Repair Wrist Arthritis Distal Radius Fractures Scapholunate

Surgery is dangerous Anatomy does not correlate with outcome

• In the older patient
• Low functional demands

Anatomy might correlate somewhat with outcome

• In younger patients
• High functional demands

Temper your enthusiasm to fix everything

Risks of k wires

26-28% risk of complication!!

24McFayden I, Field J, McCann P, Ward J, Nicol S, Curwen C.

Should unstable extra-articular distal radial fractures be treated with fixed-angle volar locked plates or percutaneous Kirschner wires? A prospective randomised controlled trial. Injury, 2011; 42(2):162-166.

25Rozental TD, Blazar PE, Franko OI, Chacko AT, Earp BE, Day CS.

Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A Prospective randomized trial. J Bone Joint Surg Am, 2009; 91(8):1837-1846.

J Hand Surg (E) 2014 39: 745-56 complication rate 16%, 8% material

J Hand Surg (E) 2013;38:118-25

Anatomy may make a difference in younger people

Gliatis, Plessas and Davis (2000) Outcome of distal radius fracture in young people. J Hand Surg 25B;6:535-543 Grewal and McDermid (2007) The Risk of Adverse Outcomes in Extra-Articular Distal Radius Fractures Is Increased With Malalignment in Patients of All Ages but Mitigated in Older Patients J Hand Surg 32(a) 962-970

Over 60 to 65 years No difference for surgery vs non-op

Chen Y, Chen X, Li Z, Yan H, Zhou F, Gao W., Safety and Efficacy of Operative Versus Nonsurgical Management of Distal Radius Fractures in Elderly Patients: A Systematic Review and Meta-analysis. J Hand Surg Am 2016; 41:404-13. Lutz K, Yeoh KM, MacDermid JC, Symonette C, Grewal R. Complications associated with operative versus nonsurgical treatment of distal radius fractures in patients aged 65 years and older. J Hand Surg Am, 2014; 39:1280-6.

So, should we fix distal radius fractures?

Earlier restoration of function

• Avoid POP
• Early movement

Restoration of rotation

• Dorsal angulation

Improved strength

• Midcarpal malalignment

Ulno-carpal abutment

• Positive ulnar variance

But to avoid OA

No evidence…….

How many of these…..

End up with these…?

Very unlikely!

• Kopylov P, et al 1993 Fractures of the distal end of the radius in young adults: a 30 year follow

up J Hand Surg 18B:45-49

• Haus BM, Jupiter JB 2009 Intra-articular fractures of the distal end of the radius in young adults:

reexamined as evidence based and outcomes medicine JBJS(Am) 2009;91A:2984-91

• Goldfarb CA et al 2006 Fifteen year outcome of displaced intra-articular fractures of the distal

radius J Hand Surg 31A:633-639Warwick et al 1993 Function 10 years after Colles’ Fracture CORR 295:270-274

• Forward, Davis, Sithole 2008 Do young patient with malunited fractures of the distal radius

inevitably develop symptomatic post-traumatic osteoarthritis? JBJS 90B:629-637

• Lutz et al 2007 Long term results following ORIF of dorsal dislocated distal intra-articular

fractures Handchir Mikrochir Plast Chir 39:54-59

Why is the risk lower?

• Concave surfaces
• tolerate incongruity
• Non-weight bearing
• Less load
• Less impact
• Discrepancy usual in the hand
• OA vs Symptoms
• Thumb base
• Heberdon’s nodes
• Radioscaphoid

Conclusion

• OA is not inevitable
• after a displaced intra-articular fracture
• or extra-articular malunion
• Even if OA develops
• it will probably not be symptomatic
• Fractures can be fixed into a perfect position
• and they may still get OA

Plates or wires?

Methods

• 461 patients
• Randomised
• K wire vs VP
• Outcomes at 3,1,12 months
• PRWE
• QuickDASH
• Pain
• Complications

Outcome

• No difference

Costa ML, Achten J, Parsons NR et al. Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of distal radius: randomised controlled trial. BMJ. 2014, 349: 4807-16

Criticisms

• 4600 eligible patients, 461 entered
• Excluded fractures which cannot be reduced closed!
• Skill of surgeon
• 2/3 by non consultants
• 13 % surgeons done less than 10 VPs
• 13 % surgeons done less than 20 VPs
• Radiology better for VP
• DASH better (not MID)
• 82% low energy
• 75% over 50 (vs 60% national)
• Did not measure early improvement <3months
• eg return to work

Earlier return to function with VLP over K wire

• Arora R, Lutz M, Deml C, Krappinger D, Haug L,

Gabl M. A prospective randomized controlled trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty- five years of age and older. J Bone Joint Surg Am, 2011; 93:2146-2153

• Rozental TD, Blazar PE, Franko OI, Chacko AT,

Earp BE, Day CS. Functional outcomes for unstable distal radial fractures treated with

• pen reduction and internal fixation or closed

reduction and percutaneous fixation. A Prospective randomized trial. J Bone Joint Surg Am, 2009; 91(8):1837-1846.

• Karantana A, Downing ND, Forward DP et al.

Surgical treatment of distal radial fractures with a volar locking plate versus conventional percutaneous methods: a randomized controlled trial. JBJS (Am) 2-13. Oct 2:95 (19): 1737-44

• Substantially improved function

at 6 weeks, evaporated by 3 months

Other studies

Meta-analysis

Chaudhry et al 2015 Are Volar Locking Plates Superior to Percutaneous K-wires for Distal Radius Fractures? A Meta-analysis. 473:3017-27 Slightly better early outcome for VP at 3 months

• DASH
• Supination, flexion
• RR infection for K wire 2.6 (8.2% vs 3.2%)

Francheschi et al (2015). Volar locking plates versus K-wire/pin fixation for the treatment of distal radial fractures: a systematic review and quantitative synthesis. Br Med Bull.115:91-110

• No difference except DASH

• Vitamin C
• No evidence it prevents CRPS
• Radiological parameters
• Insufficient evidence to correlate with patient

rated outcome

• Immobilisation
• In neutral not flexed
• 4 weeks not 6
• Check Xrays
• At 2 to 3 weeks
• If unstable
• If a change in position would prompt surgery
• No need at time of POP removal

• Over 65 years
• Evidence that surgery does not improve PROMs
• Which operation
• ORIF not superior to K-wires at 1 year (level1+)
• Only applies to reducible fractures
• ? Function ant 6 weeks
• No need to fix the ulnar styloid
• Use ORIF rather then ExFix (level 1++)

Surgery within

 72 hours-intra-articular fractures  1 week extra-articular fractures  72 hours- re-displaced fractures

If surgery needed

 Offer k-wires

• No intra-articular displacement
• Closed reduction possible

 Offer ORIF

If not

Dupuytren’s Disease Flexor Tendon Repair Wrist Arthritis Distal Radius Fractures Scapholunate

• 17 papers
• Pain
• pre-op 6
• post op 2.8
• Grip strength
• +11% tenodesis
• +31% capsulodesis
• Radioulnar arc
• +19% capsulodesis
• -11% tenodesis
• Radiological gap recurs
• Does not correlate with outcome
• Very short follow up
• Only 4 papers > 4 years….

Prof David Warwick

MD FRCS FRCS(Orth) European Diploma of Hand Surgery

www.handsurgery.co.uk

Hand and Wrist

BOA Instructional Course Manchester 2019